5 Things you might see with Knee Pain outside of the normal

This week’s post title is a bit mis-leading because some of you may see this stuff with your knee pain patients already and it is “normal” for you, but I thought for many people these things may be interesting as they fall outside of the realm of the topics more commonly written about with knee pain. That would include, restricted dorsiflexion, tight hips, weak hips, quad dominant mover, valgus collapse due to weakness etc. The list could go on.

As someone who had “PFPS”type symptoms in the past I have had a lot of experience trying different approaches to rehab from other practitioners and lots of different self practices as well. I love treating knee pain now as I feel it can be managed quite easily, but takes a willingness from the patient to make appropriate changes in lifestyle and exercise focus.

This 5 point article could literally be 50 points with all the things I have picked up with knee pain over the years and I plan on sharing more points about knee pain in the future as it is my favourite topic. In general there are really only 4 types of knee pain in my head, but there are more specific ones that are less common than these 4:

  1. Overuse knee pain: Back off bro….you might be over doing it. Needs rest and maybe to address overall movement quality, but the client is likely just over doing it. Cross fitters, gym rats, and cardio junky patients. If you rest and it keeps coming back. See point 2 or 4.
  2. Weakness knee pain: This is typically your sedentary, teenage athlete, and often cardio junky patients. Often bilateral. These people are often just poor movers and with a good overall strengthening program and likely some anterior chain mobility  they can notice great benefit to prior knee pain.
  3. Degenerative knee pain: I’m still surprised how many people I see that have had 2+ knee surgeries and their knee is just fairly messy.”When I was 15 I tore my ACL, and when I was 25 I tore my meniscus, then at 30 I fractured my knee cap, then at 40 I tore my ACL again.” The above isn’t any specific patient I have had, but it’s an all too common knee abuse history! Bone on bone, old meniscus tears, can’t fully flex their knee, can’t fully extend their knee etc. These knees are a mess, but that doesn’t mean they can’t be helped and that the above means they need to become sedentary. Again, typically with a strengthening program and given some knee sparing strategies (lots of hip dominant movement education) these people can have huge advantages to rehab that they may not have had in previous injury management.
  4. Biomechanical loading knee pain: This is what we are going to dive into today and probably any future posts on knee pain. These are the knee pains that won’t get better no matter how much clamshell and hip bridge you throw at it. Even “functional” exercises like side planks, single leg RDLs and anything else you can think of will only provide minimal benefit. They provide minimal benefit to these patients because their knee is in pain because of how it is being loaded due to a completely dysfunctional system. Their mid foot is like a rock, their ankle has no DF, their subtalar has no rocking motion, their tibia has no rotation, their tibiofemoral joint line is stiff, muscular imbalances all over the place and their hip capsule is like glue etc. Sometimes it may be one driver, sometimes two, but often times people fall into a complete dysfunctional leg category where there are compensations literally all over the place that need to be addressed in the restoration of knee function. One of the biggest influencers on my practice has been Dr. Andreo Spina, whose theory of “make stuff move nice” prior to loading has been something I find to be all to important. Someone with the above dysfunctional movements won’t even be able to “access” their glutes appropriately to do certain hip strengthening exercises and are likely just going to compensate by using deeper hip muscles and make things worse. These people can often be good movers overall and may have been frustrated by their knee pain to the point that they have gotten an MRI and it shows no damage. “So why the hell do I have knee pain??? MRI shows no damage and my technique is way better than Knee buckling Nick. What gives?” These were my thoughts when I experienced knee pain and have heard it over and over again over the years as well. It is a loading issue, not a tissue damage issue.

Back to the beginning. I’ve seen tons of articles on knee pain and they all say the same stuff, which is why I wanted to write something that might show you some minor things you might see in your knee pain patients beyond stiff ankle, tight hip flexors, quads, hip internal rotation, weak glutes/hamstrings etc. This is stuff I felt when I was a knee pain patient myself and have realized that it almost falls into a clinical pattern for most other biomechancial loading knee pain patients as well.

  1. How the knee/tibia sits in a sitting position.

IMG_0511 (1)

You will see in the picture above that my left lower leg is angled outwards more than my right. In my case (though I am exaggerating this now), and a ton of others, this is because I had a really bad high ankle sprain years ago that I did not rehab well before I even entered physio school. The foot is always looking to be in full contact with the ground, but since my ankle/foot mechanics are quite stiff and this would not be possible if my tibia was to be aligned centrally under my femur. If it was to be aligned, my medial aspect of my foot would come up and lack contact with the ground. Therefore, my body adjusted by moving the tibia laterally in order to get the foot in it’s happy place.

This may not be something completely clinically significant as no one experiences loading pain when sitting, but I find it something interesting and something you can point out to patients immediately that shows why that left knee might be experiencing something the right is not. You can get the patient to try to align the tibia centrally and see what happens to their foot/ankle position.

2. Prone tibial alignment/dorsiflexion test


In the picture above is one of my favourite tests to see if there is dysfunction in an individual knee down. Again, you can see my left tibia is spun out into external rotation. As a practitioner, you will be able to see this, but a patient may not be able to feel it. Then what you can proceed to do is test their ankle dorsiflexion by pushing down on the forefoot. What you will likely see if someone presents like the above is the ankles actually may move fairly equally if tested in their current positions. Now, if you take the spun out side, and try align the tibia centrally or equal to the other side and test dorsiflexion I can guarantee 9/10 times you will find a decreased ability for the ankle to dorsiflex. The patient can typically feel the difference and what this shows is that the tibia has started to externally rotate to compensate for a lack of dorsiflexion.

3. A very tight biceps femoris

This is something a lot of people might already pick up on, but I think it’s important because typically when people come in with some anterior knee pain practitioners instantly think quads and ITB (and associated hip muscles). If you palpate biceps femoris on your “PFPS” knee patients though I can gaurantee it should send them through the roof relatively to their healthy side. It is a sensitive muscle regardless, but the tension in that muscle for a knee pain patient can be insane. In particular, the short head of the muscle. If you have any knee pain yourself you can palpate this yourself by palpating your lateral hamstring tendon as it inserts into your lateral knee (fibular head) and work your way up the tendon until you hit the muscle belly. You should feel an appreciable difference in muscular tone.

The biceps femoris gets so much tone for a few reasons in a typical knee pain patient. The tibia is typically spun out into external rotation which is going to bias tension more towards biceps femoris (even though it doesn’t insert there)and the individual likely has poor hip function so is going to use hamstrings instead of glutes for many different activities. This is important to note because you can’t just expect this to change with hip bridges, single legs RDLs etc. Sure those are knee friendly exercises, but the patient probably doesn’t have the ability to use their hip properly and could just be jacking up biceps femoris some more and exacerbating the lower extremity dysfunction.

4. Patient may unload their primary side

IMG_0512 (1)

As seen above, I am slightly shifting away from my left side of dysfunction. You can see my femoral alignment is vertical on my right and my left is angled so my knee is outside of my pelvis. As with point 1 this is probably going to occur because I can’t properly load my tibia under my femur. If I was to do so, my foot would feel restricted so I compensate by shifting my weight away, which then allows for my left foot to be flat on the ground. This is important and something you can pick up right away once you get the patient in standing. My hip is now abducted which is going to put my important abducting stabilizers glutes/TFL on constant tension which is likely going to result in the muscles becoming weak due to constantly being in a state of tension. Hard to see in the photo above, but you might also pick up on a femur being in a constant state of internal rotation which is all so common when a tibia likes to sit in external rotation. This can also guide treatment as you can bet those adductors (in particular pectineus) is going to be very restrictive on hip ROM.

Another thing that can happen with someone who constantly unloads their primary side is they may start to develop secondary pain on their other knee due to compensation. Very common to see a knee pain start on one side and then the other one starts to act up just a little bit or even worse than the primary side. Sometimes being aware of this compensation in standing/walking around can be more important than any mobility/stability exercise.

5. A hyper mobility into extension and valgus

I often read articles saying how important it is to regain full extension of your knee to reduce knee pain. I couldn’t agree more if that is the case you have in front of you. However, more often than not I find the painful knee to actually be hyper mobile into extension. Also, the patient may not come in with any acute knee trauma so it could be easy to skip over ligament laxity testing, but if you were to do it on an average biomechanical loading knee pain patient you would have some ligament laxity on valgus testing. Their medial knee joint has likely become hyper mobile due to it becoming the path of least resistance in loading movements.

Also their extension is hyper mobile because external rotation of the tibia on the femur is an accessory motion that combines and with anterior glide of the tibia during extension. More external rotation due to compensations = more extension ability. This doesn’t mean it is good range of motion though as knees ideally are more stable and hopefully more resilient to various forces. Both extension and flexion need to be restored with appropriate movement of the tibiofemoral joint in a neutral position without excessive motion into IR or ER.

As mentioned at the beginning, I hope this article overviewed some things you either haven’t seen in your knee pain patients, have seen but wasn’t sure if you were going crazy, or have seen a lot before, but at least found it a more interesting post than other more common knee pain articles. Thanks so much for reading and let me know your thoughts!


Dave Leyland


  1. omidreza · · Reply

    That was extremly great post
    Can you teach or suggest a way to learn the 4 category of knee pain management? As you i love knee pain treatment

    1. Thanks man! Really it comes down to subjective history and assessment of the person as a whole. They are pretty clear cut categories often, but sometimes overlap a bit. I think the portion of the blog describing all 4 clarifies how I might do so!

  2. omidreza · · Reply

    I really want to know your tretment approch for knee.that is interesting. I am tired of many plans for treat knee problems i think categorize them into 4 is really interesting

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